Regulating Workplace Safety in Psychiatric Facilities

A resident on call late at night is informed that a patient has arrived at a 24-hour walk-in service and needs to be evaluated. The resident proceeds to the lobby to meet the person, who turns out to be well known to the facility as a homeless woman who seeks hospitalization when the temperature outside dips below freezing. After the evaluation, the resident concludes that there is no clinical basis for admission and refers her to a public facility for the homeless where she can get shelter for the night. Infuriated, the patient grabs the bag of possessions she has been carrying, hits the resident on the head, and winds up for additional blows. Without anyone nearby to call for assistance, the resident takes off down a hallway with the patient in pursuit and darts up a stairwell, where he is able to elude the patient and call security.

Patient assault is a frequent concern in psychiatric settings, especially in emergency or crisis settings and inpatient units, as this resident’s experience illustrates. Health care and social service entities are the most common workplace settings where employee injury occurs (1), and psychiatric hospitals and substance use disorder clinics have higher rates of nonfatal workplace injuries and illnesses than any other type of health care facility (2). A recent systematic review of studies of violence on inpatient psychiatric units found that 25%–85% of respondents reported having been the victim of patient assault in the previous year (3). Nursing staff, who are most frequently in contact with patients, are also most likely to be the targets of patient violence, with one study estimating a frequency approaching one episode per nurse per month (4). The consequences of workplace violence include physical injury, time away from work, demoralization, job turnover, and posttraumatic stress (5). Indeed, as the then-resident who was chased down the hallway by a patient angry at having been refused admission, I recall the episode vividly many decades later.

Given the frequency of assaults in psychiatric facilities, it is encouraging that the federal government is beginning to pay attention to this problem. Staff members in psychiatric facilities are sometimes too willing to accept the risk for assault and injury as “just part of the job,” but that attitude appears to be changing. A recent complaint against a psychiatric hospital not far from Denver exemplifies both the scope of the problem and how a federal law, the Occupational Safety and Health Act of 1970, can be used to help (6).

Complaining About Patient Violence

Centennial Peaks Hospital is a 104-bed, stand-alone psychiatric facility in Louisville, Colorado, owned by Universal Health Services (UHS), owner of the largest chain of psychiatric hospitals in the United States. Nearly 4,000 patients are admitted to Centennial Peaks each year, many involuntarily, to be cared for by approximately 250 staff. In 2018, an employee filed an anonymous complaint with the Denver office of the U.S. Occupational Safety and Health Administration (OSHA), which is charged with enforcing federal law protecting workers from workplace illness and injury. The complaint alleged that staff at Centennial Peaks were subject to assaults and injury by patients due, in part, to low staffing levels, especially on the facility’s two intensive treatment units, and that the hospital did not have an effective workplace violence prevention plan in place. Receipt of the complaint led to an inspection of the facility by an OSHA Compliance Safety and Health Officer.

After the site visit, which included review of records and interviews with employees, the OSHA officer concluded that the facility had violated the so-called general duty clause of the Occupational Safety and Health Act, requiring that an employer covered by the act “shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees” (7). Specifically, the inspection found that “[e]mployees, including nurses and mental health counselors, were exposed to incidents of violent behavior by patients that resulted in serious injuries including bites, sprains, lacerations, bruising, scratches, concussion, and injuries to the head, torso, and legs from punches, kicks, forceful grabs, pushes, and tripping. Employees were exposed to the hazard of physical threats and assaults during routine interactions with patients who had known histories of violent behavior. The employer had not established or implemented effective measures to protect employees from assaults or other physical violence in the workplace” (8). The report concluded that a fine of $10,229 should be imposed and that the hospital should be required to undertake a comprehensive corrective action plan.

UHS of Centennial Peaks exercised its right to contest the findings and have the case reviewed by the federal Occupational Safety and Health Review Commission. The commission is an independent agency established by Congress to decide contested cases of alleged OSHA violations. Employers can challenge the procedures and substance of OSHA findings at hearings overseen by an administrative law judge—effectively acting as a court to afford due process to businesses whose workplaces have been found to be unsafe. However, before the trial in this case took place, UHS of Centennial Peaks was penalized for failing to preserve evidence after having been notified of pending litigation. The penalty was imposed because video recordings of violent incidents at Centennial Peaks Hospital were apparently deleted. Destruction of evidence typically allows a court to draw inferences against the party that controlled the evidence. Here, the court concluded that the recordings would have shown the presence of workplace violence and the hospital’s awareness of the risk posed to its employees and that the only remaining issue for trial was whether the plan proposed by OSHA for abatement of that risk was feasible.

Documenting Safety Deficiencies

What does an unsafe psychiatric workplace look like? In a lengthy written opinion following the hearing, the judge began by cataloging the deficiencies that had been demonstrated to exist at Centennial Peaks Hospital. Staffing levels were determined by a preset matrix, which the court noted resulted in identical staffing regardless of the unit type (e.g., intensive adult vs. adolescent), number of patients, patient acuity, and shift. Even so, frequently fewer staff were on duty than the matrix called for, sometimes leaving single staff members alone on a unit with more than 20 patients. One of the issues highlighted was “insufficient staff to participate in patient restraints or de-escalation and insufficient staff to even respond to a code during overnight shifts” (6). Indeed, the opinion recounted one instance in which “patients had to step in to help a staff member whose head was being repeatedly smashed against the ground even though a Code Green (emergency call) had been called over the [public address] system.”

Tracking patient violence was another deficiency, with many of the assaults and injuries not making their way into the log that the facility was required to keep under OSHA rules. The investigator, assembling data from multiple sources, concluded that 46 injuries had occurred in 2018 and, as an indication of the seriousness of the attacks, “[o]f the assaults that led to employee injuries, 25 involved police intervention, and most of those involved arrest.” A particular locus of violence was the nursing station, where patients had jumped over the counter to attack staff and had thrown the station’s computer monitors at staff. One patient was reported to have gone “behind the nurse’s station eight times over the course of just under a month, during which he assaulted multiple employees and smashed multiple computer monitors.”

Calling for help when violence seemed imminent was also a problem. The procedure for calling a “Code Green” relied on someone at the nursing station on each unit broadcasting the alert over the facility’s public address system. Thus, a staff member elsewhere on the unit confronting an emergency would have to shout loudly, hoping that someone at the nursing station would hear the cry and respond. If only one staff member were on the unit, that person would have to make their way to the nursing station to call a code. Implementation of a policy to reduce or eliminate restraint of patients coincided with an increase in the number of patient assaults on staff and consequent injuries and was ultimately abandoned. Routine debriefings after violent episodes either never took place or focused on critiquing staff behavior rather than understanding the precipitants and how the violence might have been prevented. Although a workplace violence prevention plan existed, it appears that staff members were not familiar with the plan and had never received specific training, and the plan, once drafted, had never been updated. In the face of this evidence, the judge found multiple deficiencies in the hospital’s approach to staff safety.

Abating Threats From Patient Violence

In light of these deficiencies, the administrative law judge ordered UHS of Centennial Peaks to implement most of the changes that had been requested by the OSHA report. These changes included the development of a new and comprehensive workplace violence prevention plan that is regularly reviewed and updated, with a system for tracking and recording patient violence against staff. Expert testimony introduced at trial indicated that psychiatric units that had implemented a comprehensive program of this sort could reduce violence-related injuries from patient assaults by 60% within 2 years. In place of the “shout-out” approach to calling a code for a patient emergency, the court required staff to be equipped with walkie-talkies or panic alarms. The hospital was also ordered to reconfigure its nursing station to prevent patients from entering at will, leaping over counters, and grabbing equipment and other items that could be used as projectiles.

Ensuring adequate staffing was another important component of remediating the unsafe conditions at Centennial Peaks. Although OSHA did not recommend specific staffing levels, it did insist that levels account for census, acuity, patient violence, and other factors, a requirement that was upheld by the court. Training for clinical staff on the overall violence prevention plan was also found to be “crucial to engaging in an all-encompassing process to prevent workplace violence.” Finally, a process of postincident debriefing and investigation was deemed vital to minimizing patient violence, including consideration not just of episodes involving actual violence but also of “near misses” that could hold lessons for preventing future episodes. Taken as a whole, the opinion concluded that “the most important takeaway from this case is the importance of an all-encompassing, systematic approach to workplace violence.” It also upheld the rather modest fine that was imposed on the facility.

The outcome of this case has obvious importance for the staff at Centennial Peaks. But its lessons are no less crucial for clinical staff in other psychiatric inpatient, outpatient, and emergency settings. Despite the frequency of patient assault in psychiatric settings, being assaulted and injured should not be considered to be an expectation of the job in psychiatric facilities. Although no set of procedures can be guaranteed to prevent all acts of violence—as the court considering the Centennial Peaks case acknowledged—psychiatric facilities, like other workplaces covered by the Occupational Safety and Health Act, are obligated to develop reasonable approaches to mitigate the risks their employees face. The outcome of the Centennial Peaks case underscores the importance of reporting unsafe conditions to OSHA, especially if a facility has not been responsive to requests to adopt measures to increase staff safety. OSHA’s recognition of the high rates of violence that occur in psychiatric settings and willingness to pursue cases involving these facilities offer hope to the professionals and paraprofessionals who work with psychiatric patients that their safety will be a priority in the psychiatric workplace.